ACC/AHA Valvular Heart Disease Guidelines Pocket Guide & App

AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease Pocket Guide Cover

Valvular Heart Disease GUIDELINES Pocket Guide

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American College of Cardiology Foundation

American Heart Association

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Key Points

Disease stages in patients with valvular heart disease should be classified (Stages A, B, C, and D) on the basis of symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation.
In the evaluation of a patient with valvular heart disease, history and physical examination findings should be correlated with the results of noninvasive testing (i.e., ECG, chest x-ray, transthoracic echocardiogram). If there is discordance between the physical examination and initial noninvasive testing, consider further noninvasive (computed tomography, cardiac magnetic resonance imaging, stress testing) or invasive (transesophageal echocardiography, cardiac catheterization) testing to determine optimal treatment strategy.
For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events, with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant, should be made in a shared decision-making process based on the CHA₂DS₂-VASc score. Patients with rheumatic mitral stenosis or a mechanical prosthesis and atrial fibrillation should receive oral anticoagulation with a vitamin K antagonist.
All patients with severe valvular heart disease being considered for valve intervention should be evaluated by a multidisciplinary team, with either referral to or consultation with a Primary or Comprehensive Valve Center.
Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Earlier intervention may be considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.
Indications for transcatheter aortic valve implantation are expanding as a result of multiple randomized trials of transcatheter aortic valve implantation atrioversus surgical aortic valve replacement. The choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve (mechanical versus bioprosthetic) and type of approach (transcatheter versus surgical).
Indications for intervention for valvular regurgitation are relief of symptoms and prevention of the irreversible long-term consequences of left ventricular volume overload. Thresholds for intervention now are lower than they were previously because of more durable treatment options and lower procedural risks.
A mitral transcatheter edge-to-edge repair is of benefit to patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery, as well as to a select subset of patients with secondary mitral regurgitation who remain severely symptomatic despite guideline-directed management and therapy for heart failure.
Patients presenting with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and atrial fibrillation, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney.
Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.

Treatment

Table 1. Evaluation of Patients With Known or Suspected VHD

Reason	Test	Indication
Initial evaluation: All patients with known or suspected valve disease	TTE*	Establishes chamber size and function, valve morphology and severity, and effect on pulmonary and systemic circulation
	History and physical	Establishes symptom severity, comorbidities, valve disease presence and severity, and presence of HF
	ECG	Establishes rhythm, LV function, and presence or absence of hypertrophy
Further diagnostic testing: Information required for equivocal symptom status, discrepancy between examination and echocardiogram, further definition of valve disease, or assessing response of the ventricles and pulmonary circulation to load and to exercise	Chest x-ray	Important for the symptomatic patient; establishes heart size and presence or absence of pulmonary vascular congestion, intrinsic lung disease, and calcification of aorta and pericardium
	TEE	Provides high-quality assessment of mitral and prosthetic valve, including definition of intracardiac masses and possible associated abnormalities (e.g., intracardiac abscess, LA thrombus)
	CMR	Provides assessment of LV volumes and function, valve severity, and aortic disease
	PET CT	Aids in determination of active infection or inflammation
	Stress testing	Gives an objective measure of exercise capacity
	Catheterization	Provides measurement of intracardiac and pulmonary pressures, valve severity, and hemodynamic response to exercise and drugs
Further risk stratification: Information on future risk of the valve disease, which is important for determination of timing of intervention	Biomarkers	Provide indirect assessment of filling pressures and myocardial damage
	TTE strain	Helps assess intrinsic myocardial performance
	CMR	Assesses fibrosis by gadolinium enhancement
	Stress testing	Provides prognostic markers
	Procedural risk	Quantified by STS (Predicted Risk of Mortality) and TAVI scores
	Frailty score	Provides assessment of risk of procedure and chance of recovery of quality of life
Preprocedural testing: Testing required before valve intervention	Dental examination	Rules out potential infection sources
	CT coronary angiogram or invasive coronary angiogram	Gives an assessment of coronary anatomy
	CT: peripheral	Assesses femoral access for TAVI and other transcatheter procedures
	CT: cardiac	Assesses suitability for TAVI and other transcatheter procedures

* TTE is the standard initial diagnostic test in the initial evaluation of patients with known or suspected VHD.

Table 2. Stages of Progression of VHD

Stage	Definition	Description
A	At risk	Patients with risk factors for development of VHD
B	Progressive	Patients with progressive VHD (mild-to-moderate severity and asymptomatic)
C	Asymptomatic severe	Asymptomatic patients who meet the criteria for severe VHD: C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
D	Symptomatic severe	Patients who have developed symptoms as a result of VHD

Table 3. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal Left Ventricular (LV) Function

Stage	Valve Lesion
Stage	AS*	AR	MS	MR
Progressive (stage B)	Every 3–5 y (mild severity; V_max 2.0–2.9 m/s)	Every 3–5 y (mild severity)	Every 3–5 y (mitral valve area [MVA] >1.5 cm²)	Every 3–5 y (mild severity)
Progressive (stage B)	Every 1–2 y (moderate severity; V_max 3.0–3.9 m/s)	Every 1–2 y (moderate severity)	Every 3–5 y (mitral valve area [MVA] >1.5 cm²)	Every 1–2 y (moderate severity)
Severe asymptomatic (stage C1)	Every 6–12 mo (V_max ≥4 m/s)	Every 6–12 mo	Every 1–2 y (MVA 1.0–1.5 cm²)	Every 6–12 mo
Severe asymptomatic (stage C1)	Every 6–12 mo (V_max ≥4 m/s)	Dilating LV: more frequently	Every year (MVA <1.0 cm²)	Dilating LV: more frequently

Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single-valve lesions. These intervals apply to most patients with each valve lesion and do not take into consideration the etiology of the valve disease.
* With normal stroke volume.

Table 4. Secondary Prevention of Rheumatic Fever

Antibiotics for Prevention	Dosage*
Penicillin G benzathine	1.2 million U intramuscularly every 4 wk^†
Penicillin V potassium	200 mg orally twice daily
Sulfadiazine	1 g orally once daily
Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine)^‡	Varies

* In patients with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be ≥10 y or until the patient is 40 y of age (whichever is longer). Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement.
^† Administration every 3 wk is recommended in certain high-risk situations.
^‡ Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors.

Table 5. Duration of Secondary Prophylaxis for Rheumatic Fever

Type	Duration After Last Attack*
Rheumatic fever with carditis and residual heart disease (persistent VHD^†)	10 y or until patient is 40 y of age (whichever is longer)
Rheumatic fever with carditis but no residual heart disease (no valvular disease^†)	10 y or until patient is 21 y of age (whichever is longer)
Rheumatic fever without carditis	5 y or until patient is 21 y of age (whichever is longer)

* Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement.
^† Clinical or echocardiographic evidence.

2.4.1. Secondary Prevention of Rheumatic Fever

COR	LOE	Recommendations
1	C-EO	In patients with rheumatic heart disease, secondary prevention of rheumatic fever is indicated (Tables 4 and 5).

2.4.2. IE Prophylaxis

COR	LOE	Recommendations
2a	C-LD	Antibiotic prophylaxis is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with VHD who have any of the following: Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts. Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips. Previous IE. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve.
3: No Benefit	B-NR	In patients with VHD who are at high risk of IE, antibiotic prophylaxis is not recommended for nondental procedures (e.g., TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection.

2.4.3. Anticoagulation for AF in Patients With VHD

COR	LOE	Recommendations
1	A	For patients with AF and native valve heart disease (except rheumatic mitral stenosis [MS]) or who received a bioprosthetic valve >3 months ago, a non–vitamin K oral anticoagulant (NOAC) is an effective alternative to VKA anticoagulation and should be administered on the basis of the patient’s CHA₂DS₂-VASc score.
1	C-EO	For patients with AF and rheumatic MS, long-term VKA oral anticoagulation is recommended.
2a	B-NR	For patients with new-onset AF ≤3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with a VKA is reasonable.
3: Harm	B-R	In patients with mechanical heart valves with or without AF who require long-term anticoagulation with VKA to prevent valve thrombosis, NOACs are not recommended.

Figure 1. Anticoagulation for AF in Patients With VHD

Colors correspond to the Class of Recommendation

2.5. Evaluation of Surgical and Interventional Risk

COR	LOE	Recommendations
1	C-EO	For patients with VHD for whom intervention is contemplated, individual risks should be calculated for specific surgical and/or transcatheter procedures, using online tools when available, and discussed before the procedure as a part of a shared decision-making process.

Table 6. Risk Assessment for Surgical Valve Procedures

Criteria	Low-Risk SAVR (Must Meet ALL Criteria in This Column)	Low-Risk Surgical Mitral Valve Repair for Primary MR (Must Meet ALL Criteria in This Column)	High Surgical Risk (Any 1 Criterion in This Column)	Prohibitive Surgical Risk (Any 1 Criterion in This Column)
STS-predicted risk of death*	<3% AND	<1% AND	>8% OR	Predicted risk of death or major morbidity (all-cause) >50% at 1 y OR
Frailty^†	None AND	None AND	≥2 Indices (moderate to severe) OR	≥2 Indices (moderate to severe) OR
Cardiac or other major organ system compromise not to be improved postoperatively^‡	None AND	None AND	1 to 2 Organ systems OR	≥3 Organ systems OR
Procedure-specific impediment^§	None	None	Possible procedure-specific impediment	Severe procedure-specific impediment

* Use of the STS Predicted Risk of Mortality (http://riskcalc.sts.org/stswebriskcalc/#/) to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of the STS average observed/expected mortality ratio for the procedure in question. The EUROSCORE II risk calculator may also be considered for use and is available at http://www.euroscore.org/calc.html.
^† Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) plus independence in ambulation (no walking aid or assistance required, or completion of a 5-m walk in <6 s). Other scoring systems can be applied to calculate no, mild, or moderate to severe frailty.
^‡ Examples of major organ system compromise include cardiac dysfunction (severe LV systolic or diastolic dysfunction or RV dysfunction, fixed pulmonary hypertension); kidney dysfunction (chronic kidney disease, stage 3 or worse); pulmonary dysfunction (FEV1 <50% or D_LCO2 <50% of predicted); central nervous system dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, cerebrovascular accident with persistent physical limitation); gastrointestinal dysfunction (Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0); cancer (active malignancy); and liver dysfunction (any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy).
^§ Examples of procedure-specific impediments include presence of tracheostomy, heavily calcified (porcelain) ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, and radiation damage.

Table 7. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores

SAVR	TAVI	Surgical MV Repair or Replacement	Transcatheter Edge-to-Edge Mitral Valve Repair
Technical or anatomic
Prior mediastinal radiation Ascending aortic calcification (porcelain aorta may be prohibitive)	Aorto-iliac occlusive disease precluding transfemoral approach Aortic arch atherosclerosis (protuberant lesions) Severe MR or TR Low-lying coronary arteries Basal septal hypertrophy Valve morphology (e.g., bicuspid or unicuspid valve) Extensive LV outflow tract calcification	Prior sternotomy Prior mediastinal radiation Ascending aortic calcification (porcelain aorta may be prohibitive)	Multivalve disease Valve morphology (e.g., thickening, perforations, clefts, calcification, and stenosis) Prior Mitral Valve surgery
Comorbidities
Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty*	Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty*	Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty*	Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty*
Futility
STS score >15 Life expectancy <1 y Poor candidate for rehabilitation	STS score >15 Life expectancy <1 y Poor candidate for rehabilitation	STS score >15 Life expectancy <1 y Poor candidate for rehabilitation	STS score >15 Life expectancy <1 y Poor candidate for rehabilitation

* Validated frailty scores include the Katz Activities of Daily Living Score

Table 8. Median Operative Mortality Rates for Specific Surgical Procedures (STS Adult Cardiac Surgery Database, 2019

Procedure	Mortality Rate (%)
AVR	2.2
AVR and CABG	4
AVR and Mitral Valve replacement	9
Mitral Valve replacement	5
Mitral Valve replacement and CABG	9
Mitral Valve repair	1
Mitral Valve repair and CABG	5

2.6. The Multidisciplinary Heart Valve Team and Heart Valve Centers

COR	LOE	Recommendations
1	C-EO	Patients with severe VHD should be evaluated by a Multidisciplinary Heart Valve Team (MDT) when intervention is considered.
2a	C-LD	Consultation with or referral to a Primary or Comprehensive Heart Valve Center is reasonable when treatment options are being discussed for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered.

Table 9. Structure of Primary and Comprehensive Valve Centers

Comprehensive (Level I) Valve Center	Primary (Level II) Valve Center
Interventional Procedures*
TAVI–transfemoral	TAVI–transfemoral
Percutaneous aortic valve balloon dilation	Percutaneous aortic valve balloon dilation
TAVI–alternative access, including transthoracic (transaortic, transapical) and extrathoracic (e.g., subclavian, carotid, caval) approaches
Valve-in-valve procedures
Mitral transcatheter edge-to-edge repair
Prosthetic valve paravalvular leak closure
Percutaneous mitral balloon commissurotomy
Surgical Procedures*
SAVR	SAVR
Valve-sparing aortic root procedures
Aortic root procedures for aneurysmal disease
Concomitant septal myectomy with AVR
Root enlargement with AVR
Mitral repair for primary MR	Mitral repair for posterior leaflet primary MR^†
Mitral valve replacement^‡	Mitral valve replacement^‡
Multivalve operations
Reoperative valve surgery
Isolated or concomitant tricuspid valve repair or replacement	Concomitant tricuspid valve repair or replacement with mitral surgery
Imaging Personnel
Echocardiographer with expertise in valve disease and transcatheter and surgical interventions	Echocardiographer with expertise in valve disease and transcatheter and surgical interventions
Expertise in CT with application to valve assessment and procedural planning	Expertise in CT with application to valve assessment and procedural planning
Interventional echocardiographer to provide imaging guidance for transcatheter and intraoperative procedures
Expertise in cardiac MRI with application to assessment of VHD
Criteria for Imaging Personnel
A formalized role/position for a “valve echocardiographer” who performs both the pre- and postprocedural assessment of valve disease	A formalized role/position for a “valve echocardiographer” who performs both the pre- and postprocedural assessment of valve disease
A formalized role/position for the expert in CT who oversees the preprocedural assessment of patients with valve disease	A formalized role/position for the expert in CT who oversees the preprocedural assessment of patients with valve disease
A formalized role/position for an interventional echocardiographer
Institutional Facilities and Infrastructure
MDT	MDT
A formalized role/position for a dedicated valve coordinator who organizes care across the continuum and system of care	A formalized role/position for a dedicated valve coordinator who organizes care across the continuum and system of care
Cardiac anesthesia support	Cardiac anesthesia support
Palliative care team	Palliative care team
Vascular surgery support	Vascular surgery support
Neurology stroke team	Neurology stroke team
Consultative services with other cardiovascular subspecialties
Consultative services with other medical and surgical subspecialties
Echocardiography–3D TEE; comprehensive TTE for assessment of valve disease	Echocardiography–comprehensive TTE for assessment of valve disease
Cardiac CT	Cardiac CT
ICU	ICU
Temporary mechanical support (including percutaneous support devices such as intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO)	Temporary mechanical support (including percutaneous support devices such as intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO)
Left/right ventricular assist device capabilities (on-site or at an affiliated institution)
Cardiac catheterization laboratory, hybrid catheterization laboratory, or hybrid OR laboratory^§	Cardiac catheterization laboratory
PPM and ICD implantation	PPM and ICD implantation
Institutional Facilities and Infrastructure
IAC echocardiography laboratory accreditation	IAC echocardiography laboratory accreditation
24/7 intensivist coverage for ICU

* A Primary (Level II) Center may provide additional procedures traditionally offered at a Comprehensive (Level I) Center as long as the criteria for competence and outcomes are met.
^† If intraoperative imaging and surgical expertise exist.
^‡ If mitral valve anatomy is not suitable for valve repair.
^§ Equipped with a fixed radiographic imaging system and flat-panel fluoroscopy, offering catheterization laboratory-quality imaging and hemodynamic capability. Used with permission from Nishimura et al. J Am Coll Cardiol. 2019;73:2609-35.

2.7.4. Periodic Imaging After Valve Intervention

COR	LOE	Recommendations
1	C-EO	In asymptomatic patients with any type of valve intervention, a baseline postprocedural TTE followed by periodic monitoring with TTE is recommended, depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions.

Table 10. Timing of Periodic Imaging After Valve Intervention

	Imaging Follow-Up*
Valve Intervention	Minimal Imaging Frequency^†	Location
Mechanical valve (surgical)	Baseline	Primary Valve Center
Bioprosthetic valve (surgical)	Baseline, 5 and 10 y after surgery,^‡ and then annually	Primary Valve Center
Bioprosthetic valve (transcatheter)	Baseline and then annually	Primary Valve Center
Mitral valve repair (surgical)	Baseline, 1 y, and then every 2–3 y	Primary Valve Center
Mitral valve repair (transcatheter)	Baseline and then annually	Comprehensive Valve Center
Bicuspid aortic valve disease	Continued post-AVR monitoring of aortic size if aortic diameter is ≥4.0 cm at time of AVR, as detailed in Section 5.1	Primary Valve Center

* Initial postprocedural TTE is recommended for all patients, ideally 1 to 3 months after the procedure. Annual clinical follow-up is recommended annually for all patients after valve intervention at a Primary or Comprehensive Valve Center.
^† Repeat imaging is appropriate at shorter follow-up intervals for changing signs or symptoms, during pregnancy, and to monitor residual or concurrent cardiac dysfunction.
^‡ Imaging may be done more frequently in patients with bioprosthetic surgical valves if there are risk factors for early valve degeneration (e.g., younger age, renal failure, diabetes).

Table 11. Stages of AS

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AS	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis	Aortic V_max <2 m/s with normal leaflet motion	None	None
B	Progressive AS	Mild to moderate leaflet calcification/fibrosis of a bicuspid or trileaflet valve with some reduction in systolic motion or Rheumatic valve changes with commissural fusion	Mild AS: Aortic V_max 2.0–2.9 m/s or ∆P_mean <20 mm Hg Moderate AS: Aortic V_max 3.0–3.9 m/s or ∆P_mean 20–39 mm Hg	Early LV diastolic dysfunction may be present Normal left ventricular ejection fraction (LVEF)	None
C: Asymptomatic severe AS
C1	Asymptomatic severe AS	Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening	Aortic V_max ≥4 m/s or ∆P_mean ≥40 mm Hg Aortic valve area (AVA) typically ≤1.0 cm² (or AVAi 0.6 cm²/m²) but not required to define severe AS Very severe AS: Aortic V_max ≥5 m/s or ∆P_mean ≥60 mm Hg	LV diastolic dysfunction Mild LV hypertrophy Normal LVEF	None: Exercise testing is reasonable to confirm symptom status
C2	Asymptomatic severe AS with LV dysfunction	Severe leaflet calcification/fibrosis or congenital stenosis with severely reduced leaflet opening	Aortic V_max ≥4 m/s or ∆P_mean ≥40 mm Hg AVA typically ≤1.0 cm² (or AVAi 0.6 cm²/m²)	LVEF <50%	None
D: Symptomatic severe AS
D1	Symptomatic severe high- gradient AS	Severe leaflet calcification/fibrosis or congenital stenosis with severely reduced leaflet opening	Aortic V_max ≥4 m/s or ∆P_mean ≥40 mm Hg AVA typically ≤1.0 cm² (or AVAi ≤0.6 cm²/m²) but may be larger with mixed AS/AR	LV diastolic dysfunction LV hypertrophy Pulmonary hypertension (PHTN) may be present	Exertional dyspnea or decreased exercise tolerance Exertional angina Exertional syncope or presyncope
D2	Symptomatic severe low-flow/low-gradient AS with reduced LVEF	Severe leaflet calcification with severely reduced leaflet motion	AVA ≤1.0 cm² with resting aortic V_max <4 m/s or ∆P_mean <40 mm Hg Dobutamine stress echocardiography (DSE) shows AVA <1.0 cm² with V_max ≥4 m/s at any flow rate	LV diastolic dysfunction LV hypertrophy LVEF <50%	Heart failure (HF) Angina Syncope or presyncope
D3	Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS	Severe leaflet calcification/fibrosis with severely reduced leaflet motion	AVA ≤1.0 cm² (indexed AVA ≤0.6 cm²/m²) with an aortic V_max <4 m/s or ∆P_mean <40 mm Hg, AND Stroke volume index <35 mL/m² Measured when patient is normotensive (systolic blood pressure <140 mm Hg)	Increased LV relative wall thickness Small LV chamber with low stroke volume Restrictive diastolic filling LVEF ≥50%	HF Angina Syncope or presyncope

3.2.1.1. Diagnostic Testing: Initial Diagnosis

COR	LOE	Recommendations
1	A	In patients with signs or symptoms of AS or a BAV, TTE is indicated for accurate diagnosis of the cause of AS, assessment of hemodynamic severity, measurement of LV size and systolic function, and determination of prognosis and timing of valve intervention.
1	B-NR	In patients with suspected low-flow, low-gradient severe AS with normal LVEF (Stage D3), optimization of blood pressure control is recommended before measurement of AS severity by TTE, TEE, cardiac catheterization, or CMR.
2a	B-NR	In patients with suspected low-flow, low-gradient severe AS with reduced LVEF (Stage D2), low-dose dobutamine stress testing with echocardiographic or invasive hemodynamic measurements is reasonable to further define severity and assess contractile reserve.
2a	B-NR	In patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (Stages D2 and D3), calculation of the ratio of the outflow tract to aortic velocity is reasonable to further define severity.
2a	B-NR	In patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (Stages D2 and D3), measurement of aortic valve calcium score by CT imaging is reasonable to further define severity.

3.2.1.5. Diagnostic Testing: Exercise Testing

COR	LOE	Recommendations
2a	B-NR	In asymptomatic patients with severe AS (Stage C1), exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms.
3: Harm	B-NR	In symptomatic patients with severe AS (Stage D1, aortic velocity ≥4.0 m/s or mean pressure gradient ≥40 mm Hg), exercise testing should not be performed because of the risk of severe hemodynamic compromise.

3.2.2. Medical Therapy

COR	LOE	Recommendations
1	B-NR	In patients at risk of developing AS (Stage A) and in patients with asymptomatic AS (Stages B and C), hypertension should be treated according to standard GDMT, started at a low dose, and gradually titrated upward as needed, with appropriate clinical monitoring.
1	A	In all patients with calcific AS, statin therapy is indicated for primary and secondary prevention of atherosclerosis on the basis of standard risk scores.
2b	B-NR	In patients who have undergone TAVI, renin–angiotensin system blocker therapy (ACE inhibitor or ARB) may be considered to reduce the long-term risk of all-cause mortality.
3: No Benefit	A	In patients with calcific AS (Stages B and C), statin therapy is not indicated for prevention of hemodynamic progression of AS.

3.2.3. Timing of Intervention

COR	LOE	Recommendations
1	A	In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.
1	B-NR	In asymptomatic patients with severe AS and an LVEF <50% (Stage C2), AVR is indicated.
1	B-NR	In asymptomatic patients with severe AS (Stage C1) who are undergoing cardiac surgery for other indications, AVR is indicated.
1	B-NR	In symptomatic patients with low-flow, low-gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.
1	B-NR	In symptomatic patients with low-flow, low-gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.
2a	B-NR	In apparently asymptomatic patients with severe AS (Stage C1) and low surgical risk, AVR is reasonable when an exercise test demonstrates decreased exercise tolerance (normalized for age and sex) or a fall in systolic blood pressure of ≥10 mm Hg from baseline to peak exercise.
2a	B-R	In asymptomatic patients with very severe AS (defined as an aortic velocity of ≥5 m/s) and low surgical risk, AVR is reasonable.
2a	B-NR	In apparently asymptomatic patients with severe AS (Stage C1) and low surgical risk, AVR is reasonable when the serum B-type natriuretic peptide (BNP) level is >3 times normal.
2a	B-NR	In asymptomatic patients with high-gradient severe AS (Stage C1) and low surgical risk, AVR is reasonable when serial testing shows an increase in aortic velocity ≥0.3 m/s per year.
2b	B-NR	In asymptomatic patients with severe high-gradient AS (Stage C1) and a progressive decrease in LVEF on at least 3 serial imaging studies to <60%, AVR may be considered.
2b	C-EO	In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.

Figure 2. Timing of Intervention for AS

Colors correspond to the Class of Recommendation.
Arrows show the decision pathways that result in a recommendation for AVR. Periodic monitoring is indicated for all patients in whom AVR is not yet indicated, including those with asymptomatic (Stage C) and symptomatic (Stage D) AS and those with low-gradient AS (Stage D2 or D3) who do not meet the criteria for intervention.
See Section 3.2.4 for choice of valve type (mechanical versus bioprosthetic [TAVR or SAVR]) when AVR is indicated.

3.2.4.1. Choice of Mechanical Versus Bioprosthetic AVR

COR	LOE	Recommendations
1	C-EO	In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.
1	C-EO	For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.
2a	B-R	For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.
2a	B-NR	For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.
2a	B-R	In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.
2b	B-NR	In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.

3.2.4.2. Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate

COR	LOE	Recommendations
1	A	For symptomatic and asymptomatic patients with severe AS and any indication for AVR who are <65 years of age or have a life expectancy >20 years, SAVR is recommended.
1	A	For symptomatic patients with severe AS who are 65 to 80 years of age and have no anatomic contraindication to transfemoral TAVI, either SAVR or transfemoral TAVI is recommended after shared decision-making about the balance between expected patient longevity and valve durability.
1	A	For symptomatic patients with severe AS who are >80 years of age or for younger patients with a life expectancy <10 years and no anatomic contraindication to transfemoral TAVI, transfemoral TAVI is recommended in preference to SAVR.
1	B-NR	In asymptomatic patients with severe AS and an LVEF <50% who are ≤80 years of age and have no anatomic contraindication to transfemoral TAVI, the decision between TAVI and SAVR should follow the same recommendations as for symptomatic patients in Recommendations 1, 2, and 3 above.
1	B-NR	For asymptomatic patients with severe AS and an abnormal exercise test, very severe AS, rapid progression, or an elevated BNP (COR 2a indications for AVR), SAVR is recommended in preference to TAVI.
1	A	For patients with an indication for AVR for whom a bioprosthetic valve is preferred but valve or vascular anatomy or other factors are not suitable for transfemoral TAVI, SAVR is recommended.
1	A	For symptomatic patients of any age with severe AS and a high or prohibitive surgical risk, TAVI is recommended if predicted post-TAVI survival is >12 months with an acceptable quality of life.
1	C-EO	For symptomatic patients with severe AS for whom predicted post-TAVI or post-SAVR survival is <12 months or for whom minimal improvement in quality of life is expected, palliative care is recommended after shared decision-making, including discussion of patient preferences and values.
2b	C-EO	In critically ill patients with severe AS, percutaneous aortic balloon dilation may be considered as a bridge to SAVR or TAVI.

Figure 3. Choice of SAVR Versus TAVI When AVR is Indicated for Valvular AS

Colors correspond to the Class of Recommendation.
* Approximate ages, based on US Actuarial Life Expectancy tables, are provided for guidance. The balance between expected patient longevity and valve durability varies continuously across the age range, with more durable valves preferred for patients with a longer life expectancy. Bioprosthetic valve durability is finite (with shorter durability for younger patients) whereas mechanical valves are very durable but require life-long anticoagulation. Long-term (20 year) data on outcomes with surgical bioprosthetic valves is available; robust data on transcatheter bioprosthetic valves only extends to 5 years leading to uncertainty about longer term outcomes. The decision about valve type should be individualized based on patient specific factors that might affect expected longevity.
^† Placement of a transcatheter valve requires vascular anatomy that allows transfemoral delivery and the absence of aortic root dilation that would require surgical replacement. Valvular anatomy must be suitable for placement of the specific prosthetic valve including annulus size and shape, leaflet number and calcification and coronary ostial height. See ACC Expert Consensus Statement.

Table 12. A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention

	Favors SAVR	Favors TAVI	Favors Palliation
Age/life expectancy*	Younger age/longer life expectancy	Older age/fewer expected remaining years of life	Limited life expectancy
Valve anatomy	BAV Subaortic (LV outflow tract) calcification Rheumatic valve disease Small or large aortic annulus^†	Calcific AS of a trileaflet valve
Prosthetic valve preference	Mechanical or surgical bioprosthetic valve preferred Concern for patient–prosthesis mismatch (annular enlargement might be considered)	Bioprosthetic valve preferred Favorable ratio of life expectancy to valve durability TAVI provides larger valve area than same size SAVR
Concurrent cardiac conditions	Aortic dilation^‡ Severe primary MR Severe CAD requiring bypass grafting Septal hypertrophy requiring myectomy AF	Severe calcification of the ascending aorta (“porcelain” aorta)	Irreversible severe LV systolic dysfunction Severe MR attributable to annular calcification
Noncardiac conditions		Severe lung, liver, or renal disease Mobility issues (high procedural risk with sternotomy)	Symptoms likely attributable to noncardiac conditions Severe dementia Moderate to severe involvement of ≥2 other organ systems
Frailty	Not frail or few frailty measures	Frailty likely to improve after TAVI	Severe frailty unlikely to improve after TAVI
Estimated procedural or surgical risk of SAVR or TAVI	SAVR risk low TAVI risk high	TAVI risk low to medium SAVR risk high to prohibitive	Prohibitive SAVR risk (>15%) or post-TAVI life expectancy <1 y
Procedure-specific impediments	Valve anatomy, annular size, or low coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI	Previous cardiac surgery with at-risk coronary grafts Previous chest irradiation	Valve anatomy, annular size, or coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI
Goals of Care and patient preferences and values	Less uncertainty about valve durability Avoid repeat intervention Lower risk of permanent pacer Life prolongation Symptom relief Improved long-term exercise capacity and QOL Avoid vascular complications Accepts longer hospital stay, pain in recovery period	Accepts uncertainty about valve durability and possible repeat intervention Higher risk of permanent pacer Life prolongation Symptom relief Improved exercise capacity and QOL Prefers shorter hospital stay, less postprocedural pain	Life prolongation not an important goal Avoid futile or unnecessary diagnostic or therapeutic procedures Avoid procedural stroke risk Avoid possibility of cardiac pacer

* Expected remaining years of life can be estimated from U.S. Actuarial Life Expectancy tables. The balance between expected patient longevity and valve durability varies continuously across the age range, with more durable valves preferred for patients with a longer life expectancy. Bioprosthetic valve durability is finite (with shorter durability for younger patients), whereas mechanical valves are very durable but require lifelong anticoagulation. Long-term (20-y) data on outcomes with surgical bioprosthetic valves are available; robust data on transcatheter bioprosthetic valves extend only to 5 y, leading to uncertainty about longer-term outcomes. The decision about valve type should be individualized on the basis of patient-specific factors that might affect expected longevity.
^† A large aortic annulus may not be suitable for currently available transcatheter valve sizes. With a small aortic annulus or aorta, a surgical annulus-enlarging procedure may be needed to allow placement of a larger prosthesis and avoid patient–prosthesis mismatch.
^‡ Dilation of the aortic sinuses or ascending aorta may require concurrent surgical replacement, particularly in younger patients with a BAV.

Table 13. Stages of Chronic Aortic Regurgitation (AR)

Stage	Definition	Valve Anatomy	Valve Hemodynamics	Hemodynamic Consequences	Symptoms
A	At risk of AR	Bicuspid aortic valve (or other congenital valve anomaly) Aortic valve sclerosis Diseases of the aortic sinuses or ascending aorta History of rheumatic fever or known rheumatic heart disease Infective endocarditis (IE)	AR severity: none or trace	None	None
B	Progressive AR	Mild-to-moderate calcification of a trileaflet valve, bicuspid aortic valve (or other congenital valve anomaly) Dilated aortic sinuses Rheumatic valve changes Previous IE	Mild AR: Jet width <25% of left ventricular outflow tract (LVOT); Vena contracta <0.3 cm; RVol <30 mL/beat; RF <30%; Effective regurgitant orifice (ERO) <0.10 cm²; Angiography grade Moderate AR: Jet width 25%–64% of LVOT; Vena contracta 0.3–0.6 cm; RVol 30–59 mL/beat; RF 30%–49%; ERO 0.10–0.29 cm²; Angiography grade 2	Normal LV systolic function Normal LV volume or mild LV dilation	None
C	Asymptomatic severe AR	Calcific aortic valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes IE with abnormal leaflet closure or perforation	Severe AR: Jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm²; Angiography grade 3–4; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	C1: Normal LVEF (>55%) and mild to moderate LV dilation (LVESD <50 mm) C2: Abnormal LV systolic function with depressed LVEF (≤55%) or severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m²)	None; exercise testing is reasonable to confirm symptom status
D	Symptomatic severe AR	Calcific valve disease Bicuspid valve (or other congenital abnormality) Dilated aortic sinuses or ascending aorta Rheumatic valve changes Previous IE with abnormal leaflet closure or perforation	Severe AR: Doppler jet width ≥65% of LVOT; Vena contracta >0.6 cm; Holodiastolic flow reversal in the proximal abdominal aorta; RVol ≥60 mL/beat; RF ≥50%; ERO ≥0.3 cm²; Angiography grade 3–4; In addition, diagnosis of chronic severe AR requires evidence of LV dilation	Symptomatic severe AR may occur with normal systolic function (LVEF >55%), mild to moderate LV dysfunction (LVEF 40%–55%), or severe LV dysfunction (LVEF <40%) Moderate to severe LV dilation is present	Exertional dyspnea or angina or more severe HF symptoms

4.3.1. Diagnosis of Chronic AR

COR	LOE	Recommendations
1	B-NR	In patients with signs or symptoms of AR, TTE is indicated for assessment of the cause and severity of regurgitation, LV size and systolic function, prognosis, and timing of valve intervention.
1	B-NR	In patients with a BAV or with known dilation of the aortic sinuses or ascending aorta, TTE is indicated to evaluate the presence and severity of AR.
1	B-NR	In patients with moderate or severe AR and suboptimal TTE images or a discrepancy between clinical and TTE findings, TEE, CMR, or cardiac catheterization is indicated for the assessment of LV systolic function, systolic and diastolic volumes, aortic size, and AR severity.

4.3.2. Medical Therapy

COR	LOE	Recommendations
1	B-NR	In asymptomatic patients with chronic AR (Stages B and C), treatment of hypertension (systolic blood pressure >140 mm Hg) is recommended.
1	B-NR	In patients with severe AR who have symptoms and/or LV systolic dysfunction (Stages C2 and D) but a prohibitive surgical risk, GDMT for reduced LVEF with ACE inhibitors, ARBs, and/or sacubitril/valsartan is recommended.

4.3.3. Timing of Intervention

COR	LOE	Recommendations
1	B-NR	In symptomatic patients with severe AR (Stage D), aortic valve surgery is indicated regardless of LV systolic function.
1	B-NR	In asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF ≤55%) (Stage C2), aortic valve surgery is indicated if no other cause for systolic dysfunction is identified.
1	C-EO	In patients with severe AR (Stage C or D) who are undergoing cardiac surgery for other indications, aortic valve surgery is indicated.
2a	B-NR	In asymptomatic patients with severe AR and normal LV systolic function (LVEF >55%), aortic valve surgery is reasonable when the LV is severely enlarged (LVESD >50 mm or indexed LVESD 25 mm/m²) (Stage C2).
2a	C-EO	In patients with moderate AR (Stage B) who are undergoing cardiac or aortic surgery for other indications, aortic valve surgery is reasonable.
2b	B-NR	In asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF >55%; Stage C1) and low surgical risk, aortic valve surgery may be considered when there is a progressive decline in LVEF on at least 3 serial studies to the low–normal range (LVEF 55% to 60%) or a progressive increase in LV dilation into the severe range (LV end-diastolic dimension [LVEDD] 65 mm).
3: Harm	B-NR	In patients with isolated severe AR who have indications for SAVR and are candidates for surgery, TAVI should not be performed.

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Table 1. Evaluation of Patients With Known or Suspected VHD

Table 2. Stages of Progression of VHD

Table 3. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal Left Ventricular (LV) Function

Table 4. Secondary Prevention of Rheumatic Fever

Table 5. Duration of Secondary Prophylaxis for Rheumatic Fever

2.4.1. Secondary Prevention of Rheumatic Fever

2.4.2. IE Prophylaxis

2.4.3. Anticoagulation for AF in Patients With VHD

Figure 1. Anticoagulation for AF in Patients With VHD

2.5. Evaluation of Surgical and Interventional Risk

Table 6. Risk Assessment for Surgical Valve Procedures

Table 7. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores

Table 8. Median Operative Mortality Rates for Specific Surgical Procedures (STS Adult Cardiac Surgery Database, 2019

2.6. The Multidisciplinary Heart Valve Team and Heart Valve Centers

Table 9. Structure of Primary and Comprehensive Valve Centers

2.7.4. Periodic Imaging After Valve Intervention

Table 10. Timing of Periodic Imaging After Valve Intervention

Table 11. Stages of AS

3.2.1.1. Diagnostic Testing: Initial Diagnosis

3.2.1.5. Diagnostic Testing: Exercise Testing

3.2.2. Medical Therapy

3.2.3. Timing of Intervention

Figure 2. Timing of Intervention for AS

3.2.4.1. Choice of Mechanical Versus Bioprosthetic AVR

3.2.4.2. Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate

Figure 3. Choice of SAVR Versus TAVI When AVR is Indicated for Valvular AS

Table 12. A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention

Table 13. Stages of Chronic Aortic Regurgitation (AR)

4.3.1. Diagnosis of Chronic AR

4.3.2. Medical Therapy

4.3.3. Timing of Intervention

Figure 4. Timing of Intervention for AR

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Related Guidelines

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Valvular Heart Disease GUIDELINES Pocket Guide

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Valvular Heart Disease GUIDELINES Pocket Guide

Key Points

Treatment

Table 1. Evaluation of Patients With Known or Suspected VHD

Table 2. Stages of Progression of VHD

Table 3. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal Left Ventricular (LV) Function

Table 4. Secondary Prevention of Rheumatic Fever

Table 5. Duration of Secondary Prophylaxis for Rheumatic Fever

2.4.1. Secondary Prevention of Rheumatic Fever

2.4.2. IE Prophylaxis

2.4.3. Anticoagulation for AF in Patients With VHD

Figure 1. Anticoagulation for AF in Patients With VHD

2.5. Evaluation of Surgical and Interventional Risk

Table 6. Risk Assessment for Surgical Valve Procedures

Table 7. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores

Table 8. Median Operative Mortality Rates for Specific Surgical Procedures (STS Adult Cardiac Surgery Database, 2019

2.6. The Multidisciplinary Heart Valve Team and Heart Valve Centers

Table 9. Structure of Primary and Comprehensive Valve Centers

2.7.4. Periodic Imaging After Valve Intervention

Table 10. Timing of Periodic Imaging After Valve Intervention

Table 11. Stages of AS

3.2.1.1. Diagnostic Testing: Initial Diagnosis

3.2.1.5. Diagnostic Testing: Exercise Testing

3.2.2. Medical Therapy

3.2.3. Timing of Intervention

Figure 2. Timing of Intervention for AS

3.2.4.1. Choice of Mechanical Versus Bioprosthetic AVR

3.2.4.2. Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate

Figure 3. Choice of SAVR Versus TAVI When AVR is Indicated for Valvular AS

Table 12. A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention

Table 13. Stages of Chronic Aortic Regurgitation (AR)

4.3.1. Diagnosis of Chronic AR

4.3.2. Medical Therapy

4.3.3. Timing of Intervention

Figure 4. Timing of Intervention for AR